One of the biggest hurdles in the treatment of incontinence or bladder leakage
is for the patient to overcome their embarrassment and to admit that they have
a problem. If you are experiencing incontinence or bladder leakage, talk to
your healthcare provider. Taking this decisionnaire may make things a bit easier.
Check off any of the following that apply to you and take this with you on your
next visit.

___

Do you ever have any accidental loss of urine? If so, how many times per
day? ____

___

Do you ever have accidental loss of urine
during your sleep?

___

Do you have any blood in your urine? (If so, see your doctor as soon as
possible.)

___

Do you have a sense of urgency that you have to urinate ASAP and that you
might not make it to the bathroom?

___

Do you routinely urinate more than 8 times per day?

___

Do you wake up to urinate 2 or more times per night?

___

Do you have any pain with urination?

___

Do you leak urine when you cough, sneeze or laugh?

___

Do you drink coffee, colas, or other beverages containing caffeine? If
so, how many per day?____

___

Do you take any medicines that contain caffeine? (e.g. NoDoz, Excedrin,
etc.)

___

Have you changed any of your activities over time because of urine leakage
or fear of urine leakage?

___Work habits

___Dress habits (including the daily use
of pads or adult diapers)

___Carrying a change of underwear/clothing

___Travel

___Dancing, aerobics, or other activities

___Intimate relations

___Other

___

Have you had any bladder, pelvic or abdominal surgery?

___

Have you ever given birth?

___

Do you practice "toilet mapping" (being sure to know where every bathroom
is over the course of your daily travels)?